Exp. Date ___ Classification ______________

_________

The permittee agrees to indemnify, defend and hold harmless the City and/or any other City Agency, its officers, agents and employees, for/from any and all claims or actions of any kind asserted against the City and/or other City agency its officers, agents and employees arising out of the permitee (including permittee employees, representatives, product and subcontractors) negligent performance under this agreement.

5. Dig Alert Number

3. Traffic Control Plan(s)

Contractor's License No. ______________________________

Applicant ___________________________________________ Contact Person_______________________________________

Address ____________________________________________ Address ___________________________________________

City ____________________________ Zip_______________

Phone _________________ Fax _____________________

CONTRACTOR’S INFORMATION:

Contractor _________________________________________ Contact Person______________________________________

ENCROACHMENT/EXCAVATION PERMIT APPLICATION APPLICANT’S INFORMATION:

2. Approved Site Plan(s)

_________________________________________________________________________

Address/location of work: ____________________________________________________________________________

Type of work to be performed: _________________________________________________________________________

Applicant ___________________________________________ Contact Person_______________________________________

City _______________________________Zip______________

6. Insurance Certificate with City of Pico Rivera additionally insured with the following:

Excavation Length ______________ Width_______________ Depth _____________

Number of working days _________ Starting Date_________________ Completion Date______________________

4. Project Schedule shall be provided to the Public Works Inspector 2 days prior to start of job

CITY OF PICO RIVERA PUBLIC WORKS DEPARTMENT

6615 PASSONS BLVD., PICO RIVERA, CA 90660

Phone ________________ Fax ________________ Phone ________________

The following documents need to be submitted with this application:

1. Business License from the City of Pico Rivera - Contractor and Sub-Contractor(s)

AUTHORIZATION:

Hereby names the applicant for a permit to encroach in the public right of way of the City of Pico Rivera, subject to the provisions of Pico Rivera Municipal Codes and all applicable laws, rules and regulations of the City of Pico Rivera or any other public agency.

Signature __________________________ _________ _____________________________ Authorized Agent for Permittee Print Name Date

ANY QUESTIONS PLEASE CONTACT THE DEPARTMENT OF PUBLIC WORKS AT (562) 801-4404 Fill in ALL Blanks. If not applicable, write "N/A"